1. Eastman, Peggy

Article Content

A new study for the non-profit Community Oncology Alliance (COA) conducted by Avalere Health LLC shows that the COVID-19 pandemic has resulted in major declines in cancer screening, diagnosis, and treatment of American seniors and Medicare beneficiaries in 2020. Many were delaying care because of orders to shelter in place.

pandemic; mask; canc... - Click to enlarge in new windowpandemic; mask; cancer patient. pandemic; mask; cancer patient

The study, released online ahead of publication in the journal JCO Clinical Cancer Informatics, is a retrospective analysis of utilization data from a large proprietary provider-sourced data clearinghouse. Avalere Health examined billing frequencies from March to July 2020 for common cancer procedures, including cancer screenings, infusion therapies such as chemotherapy, and radiation therapy. Oncologists who took part in the study say they are concerned because they are already seeing cancers caught at later stages, when they are harder to treat. Delays could have negative long-term impacts on disease progression and overall survival in 2021 and beyond.


As previously reported by Oncology Times, the Progress Report 2020 from the American Association for Cancer Research (AACR) also found chilling effects of the pandemic on patient care and cancer research. In fact, the AACR report states that delays in cancer screenings and treatment are projected to lead to more than 10,000 additional deaths from breast and colorectal cancer over the next decade.


The Association of Community Cancer Centers (ACCC) has also expressed concern about the rise of cancer mortality and advanced rates in 2020 due to the pandemic, and has shared advice on how cancer professionals can use creative techniques to improve cancer screening (see box on page 33).


"When cancer becomes more advanced before it is detected, it becomes a ticking time bomb," said lead study author Debra Patt, MD, PhD, MBA, FASCO, Executive Vice President for Policy & Strategic Initiatives at Texas Oncology and a member of the COA Board of Directors. "The decrease in screenings, diagnosis, and treatments this year will lead to later stage cancers for patients, increasing morbidity and mortality for years to come. We need to detect cancers and stop them before it is too late. We need to alert all patients that they need to stop medical distancing and get appropriate screening and health care."


The study found significant reductions in screenings for breast cancer (-85%), colon cancer (-75%), prostate cancer (-74%), and lung cancer (-56%) during the first peak of the pandemic in April 2020 compared to April of 2019. The study also found marked reductions in cancer biopsies in April 2020 and July 2020 compared to those months in 2019 for breast (-71% to -31%), colon (-79% to -33%), and lung (-58% to -47%), respectively.


Some good news from the study is that community oncologists adapted to the demands of the COVID-19 pandemic rapidly in order to continue providing care.


"Community oncologists and their team members showed incredible resilience and resolve to deal with this severe crisis by adopting telehealth very quickly, reorganizing workflows, enhancing safety processes at their clinics, and migrating staff to work from home, among other strategies," said study co-author Lucio Gordan, MD, President and Managing Physician at Florida Cancer Specialists & Research Institute and a member of the COA Board of Directors. "Although a decrease in services was inevitable, I think the resilience of these practices absorbed what could have been a much worse situation.


"I think telehealth should continue not only during COVID-19, which is a must just to prevent more complications of COVID exposure, but also in the future. I don't think anybody wants to go back to the past, pre-telehealth," he stated.


Overall, in the new study, there was an average difference of 10 percentage points in billing frequencies between independent, community oncology settings and hospital or institutional care settings from March to July 2020, with higher billing for community oncologists (except for chemotherapy). The authors say this is likely due to the dramatic impact of COVID-19 on hospitals' resources, along with the ability of community oncology practices to adapt to the crisis and keep their doors open while complying with guidelines from the CDC and state reopening requirements.


Specifically, the new COA study found the following insights.


* The relative drop in utilization was higher for new patient evaluation and management (E/M) than for established cancer patients E/M services, which could reflect patient reluctance to visit health care providers due to COVID-19 concerns, as well as lowered rates of cancer screenings. In April 2020, billing frequencies for new patient E/M services declined by 70 percent, compared to 60 percent for E/M services for established patients.


* The greater reduction in hospital visits for cancer patients may be related to resource and supply chain constraints imposed by the influx of COVID-19 cases, as well as patient reluctance to use outpatient cancer services in the face of potential COVID-19 transmission. In April 2020, for example, billing frequencies for E/M services declined by 61 percent in independent practice settings compared to 71 percent in institutional settings.


* Increased regulatory flexibilities have led to a significant rise in the use of telehealth services, but access remains an obstacle for many cancer patients, especially when the services needed cannot be feasibly rendered at a distance.


* Providers in independent practice settings have had significantly greater adoption of telehealth in response to COVID-19 than have those in institutional settings. From March to July of 2020, usage claims for cancer-related telehealth ranged from 95 percent to 97 percent for independent community oncology practitioners, compared to 6 percent or lower for institutional settings during that time period. The study suggests that limited use of telehealth in hospital settings could be attributed to more limited hospital resources due to the additional strain of COVID-19 cases.



On Sept. 24, 2020, the COA Board of Directors issued a position statement supporting the use of telehealth as a valuable supplement to in-person visits during the pandemic and continued appropriate usage when the pandemic has subsided.


In the position statement, Patt stated, "Telehealth isn't a replacement for in-person visits, but it has allowed us to keep seeing new and existing patients at a time when coming into the office could be life-threatening to them. Cancer does not stop for COVID, which is why it has been absolutely critical for us to continue seeing patients and getting them the care they need."


Mark Thompson, MD, COA's Medical Director of Public Policy, praised the federal government's expansion of telehealth during the pandemic. "Prior to the COVID-19 pandemic, telehealth regulations were extremely cumbersome and limiting at the state and federal levels, with poor reimbursement," he said. "The rapid response of federal policymakers to loosen telehealth restrictions and raise reimbursement rates were a true lifesaver for patients and practices."


* Reductions in cancer screenings have long-term implications for the number of biopsies in subsequent months, as these patients could now have delayed diagnoses until their next scheduled cancer screening or until their disease becomes symptomatic.


* Reductions in infusion services in July 2020 and later months may be attributable to delayed and postponed cancer screenings. In April 2020 billing for chemotherapy services was down by 28 percent for independent community practices and 21 percent for institutional practices.


* There were decreases in cancer-related surgeries in April 2020 and July 2020 compared to those months in 2019. Decreased cancer surgeries include mastectomies, colectomies, and prostatectomies. These decreases reflect the impact of COVID-19 on cancer treatment pathways; the decreases during the pandemic reflect treatment guidelines allowing surgeries to be delayed. Decreases in later months may also reflect the downstream impact of delayed or missed cancer screenings.



Peggy Eastman is a contributing writer.


Cancer Screening During COVID-19

Randall A. Oyer, MD, President of the American Association of Community Cancer Centers (ACCC) and Medical Director of the Oncology Program at Penn Medicine Lancaster General Health, expressed the ACCC's concerns regarding cancer screening during the pandemic: "After so many years of steady decrease in both mortality and late-stage diagnosis rates, the health care community understood the catastrophic impact that COVID-19 might have on screenings and diagnoses. The rise in advanced metastatic rates and change in death rates we a dire warning to all sectors of health care to do whatever it takes to encourage screenings and reassure patients."


The ACCC recommends the following to improve cancer screening:


* Use of mobile medical clinics to deliver cancer screenings;


* Development and dissemination of safety protocols directly to patients-and through social media-to show how hospitals and clinics are keeping patients safe;


* Outreach and education to local media and community organizations about new measures to ensure safe screenings and the importance of not putting off regular appointments, and to ask for their help to disseminate this information and encourage patients to resume screenings; and


* Proactive outreach to patients to remind them of their need for screenings, and to engage in personal conversations to allay their fears, rather than waiting for patients to schedule or re-schedule their appointments.



Oyer said the ACCC is using online resources to address the financial impact of COVID-19, which can affect patients' decisions to delay cancer screenings or treatments.